Active Surveillance for Prostate Cancer

Keyan Salari, MD, PhD, is the director of the High-risk Prostate Cancer Clinic within the Massachusetts General Hospital Department of Urology, and a urologic oncologist with the Mass General Cancer Center. In this video, he discusses his team's work to identify the features of seemingly indolent prostate cancers that actually make them more aggressive.

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Transcript

One of the unique things about prostate cancer is that not all prostate cancers that are diagnosed necessarily need to be treated. There's a large number of prostate cancers that prove to be lethal, but identifying those cancers amongst the vast number of indolent prostate cancers can be quite challenging clinically. So one of our research focuses is trying to identify features of prostate cancers that make them more aggressive when they otherwise appear indolent.

We often use active surveillance, which is a strategy to avoid or defer treatment for prostate cancer in cases that look indolent, but we're not always correct about that classification, and the tools that we use to classify prostate cancers as indolent versus aggressive is not perfect and so we are always looking for ways to improve on that.

One recent area of interest has been looking at the role of family history as a tool to identify potentially more aggressive cases. There have been a number of genetic factors that are associated with more aggressive forms of prostate cancer, higher Gleason score, being diagnosed at a younger age. We did a study to see whether or not having a strong family history of prostate cancer, as well as related cancers like breast and ovarian cancer that suggest a hereditary syndrome, might be a risk factor for men who embark on active surveillance.

The results of the research study on family history and active surveillance can be directly used for counseling patients who are about to embark on active surveillance. So when you have a newly diagnosed patient who has what appears to be low-risk prostate cancer and is a suitable candidate otherwise for active surveillance, what our study shows is that if that patient has a strong family history of prostate, breast, ovarian or pancreatic cancer, that kind of together fit into a syndrome of what is termed hereditary breast and ovarian cancer syndrome. Those patients have about a 40% to 50% increased risk of having their disease progress on surveillance and thereby needing treatment. It doesn't mean that they're disqualified from active surveillance, but I believe it should be included in the counseling conversation to inform them of the risks of potentially having progression of their disease.

Every time we learn better how to classify patients, we're advancing the field of prostate cancer. That's really one of the struggles that urologic oncologists have for newly diagnosed prostate cancer patients, is to classify their disease, to reliably be able to distinguish indolent from aggressive disease, so that we can essentially try to avoid some of the side effects and risks of treatment. If there were no side effects or risks of treatment, we would treat everybody. Why take any risk with any cancer? But the reality is that radiation therapy and surgery both can have significant side effects and so in an effort to mitigate those, we would like to use active surveillance when it's safe and appropriate.

Being able to really distinguish who are the patients that we can safely watch from the patients who truly do need treatment is really the kind of, Holy Grail of classifying patients with newly diagnosed prostate cancer. And so this work is hoping to improve on that. That will help all patients who are newly diagnosed with prostate cancer.

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